The purpose of this form is to ascertain information about election changes in your jurisdiction. As we work to Restore Section 4, we need this essential information to monitor issues or potential issues in elections. Thank you in advance for the time and care you have taken in filling out this form.

Please attach any documentation, pictures, or other information in your possession to support the information provided below to votemonitor@naacpnet.org OR NAACP, Office of the General Counsel 4805 Mount Hope Drive Baltimore, MD 21215

Name of Unit*

Unit Number*

City

County

State

Congressional District and Member of Congress

City or County Style of Governance?

Name of Elections Supervisory Board

Name of Unit President

Phone Number

Email

Legal Redress Chair

President Phone Number

President Email

Political Action Chair

Telephone Number

Email Address

Check the box(es) that reflects the Election changes you’ve experienced.*

Polling place moved from college/universityPolling place not accessible via public transitConsolidated polling place in community of colorInadequate publication of new polling sitesHiring of Insensitive or unfamiliar election officialsSelection of inconvenient or intimidating voting sitesRacial or other bias manifested at siteReduced Number of Polling places

Has the governing body chosen to re-draw any of the following districts?? If so, how have the changes affected communities of color and impoverished communities.*

Please provide details regarding any redistricting change(s), including, but not limited to: identifying attempts by your county or city to redraw district lines; whether any proposed new district line splits one existing district into multiple smaller districts or merge high minority districts, or; whether any proposed new district line appears to be based on socio-economic status. If you don’t have any additional information, please type “n/a” in the box below.